1. Part of the curriculum development efforts to enhance the community health worker supervisor training. 2. Instructed the community health worker supervision training.

Provided oversight to a team of 11 Community Health Advocates assigned to primary care sites that served as liaisons between high-risk patients with social determinants of health (SDoH) needs and community-based organizations. Used program data to manage towards department milestones related metrics. Designed and streamlined SDOH related processes to achieve quality case management outcomes. Built collaborative relationships with Health Center Directors and other clinical staff to better support their sites with case management-SDoH related needs.

Designed and developed training programs for Community Health Advocates (CHAs) to enhance specific skill set to achieve quality outcomes and improve overall staff performance. Observed and evaluated CHAs performance at clinics, home visits and telephonically to identify knowledge gaps and deliver individualized training sessions.

Provide social guidance to high-risk patients enrolled in the Case Management program to improve their health and safety, such as, but not limited to Medicaid applications, home care services, food resources, free care, housing, transportation, Power of Attorney, etc. Assist the Nurse Case Managers with Spanish speaking patients during enrollments or follow-up interventions. Provide social screenings or consults to identify social barriers and refer to Nurse Case Managers if clinical intervention is needed. Support theTransitions of Care program by encouraging patients to keep post-hospitalization appointments with PCP and specialists. Support Nurse Case Manager – Lactation Consultant with Spanish interpretation during transitions of newborns and Spanish speaking moms from the Women and Infants Hospital to the health center. Utilize motivational interviewing to engage patients to participate in the Case Management program and to motivate change and achievement of goals while enrolled in the program. Provide care coordination to prevent or minimize ER admissions, inpatient admissions and remove psychosocial barriers. Provide telephonic outreach, face-to-face interventions and home visits (if required) and document interventions in the Electronic Health Record (EHR) in a timely manner. Coordinate with Nurse Case Managers educational consults for disease management such as Diabetes, Hypertension, Obesity, etc. Discuss cases with Primary Care Physicians, Specialists, Behavioral Health Team, health insurance companies and external community agencies.

Developed a 1 -year pilot Licensed Social Work position for a Transitions of Care program with the goal to measure the impact and value in cost savings by addressing social barriers during the first 7 days after the patient discharge date. Built liaisons with hospital discharge units from north and east side of Puerto Rico to facilitate discharge process for members with social determinants of health needs. Delivered quarterly presentations to the Utilization Management Department and Chief Medical Directors to discuss new processes, provide updates on data, share achievements and discuss opportunity areas.

Case managed participants with an epilepsy diagnosis. Coordinated medical and psychosocial referrals for support and welfare access. Provided guidance and education to participants and family members about epilepsy and general seizure management. Discussed cases with the multidisciplinary team. Developed care plans. Scheduled and coordinated educational activities for health professionals and the general community to raise epilepsy awareness. Completed quarterly and annual reports.

Provided preventive social-educational activities and workshops to high-risk students, with the aim of reducing teen pregnancies and dropouts. Coordinated and conducted support groups for students and family members. Facilitated referrals for community services. Completed progress notes. Developed activities, work plans, agendas and designed evaluation methods.